2 Learning Outcomes When you finish this chapter, you will be able to: 4-2When you finish this chapter, you will be able to:4.1 Describe the two methods used to schedule appointments.4.2 Explain the method used to classify patients as new or established.4.3 List the three categories of information new patients provide during telephone preregistration.4.4 Identify the information that needs to be verified for established patients when making an appointment.4.5 Describe covered and noncovered services under medical insurance policies.
3 Learning Outcomes (Continued) 4-3When you finish this chapter, you will be able to:4.6 List the three main points to verify with the payer regarding a patient’s benefits prior to a visit.4.7 Explain when a preauthorization number or referral document is required for a patient’s encounter.4.8 List the four main areas of Medisoft Network Professional’s Office Hours window.4.9 Demonstrate how to enter an appointment.4.10 Demonstrate how to book follow-up and repeating appointments.4.11 Demonstrate how to reschedule an appointment.
4 Learning Outcomes (Continued) 4-4When you finish this chapter, you will be able to:4.12 Demonstrate how to create a recall list.4.13 Demonstrate how to enter provider breaks in the schedule.4.14 Demonstrate how to print a provider’s schedule.
5 Key Terms 4-5 benefits capitation coinsurance copayment (copay) covered servicesdeductibleestablished patient (EP)fee-for-servicehealth planindemnity planmanaged caremedical insurancenew patient (NP)noncovered servicesnonparticipating (nonPAR) providerOffice Hours breakOffice Hours calendarOffice Hours patient informationout-of-networkout-of-pocketTeaching Notes: There are a lot of key terms. Following are some activities to help present them.Put students into small groups and assign each group a set of terms to define and learn. Follow up by having each group teach their set of terms to the rest of the class.Assign each student a set number of terms to define as a homework assignment. Follow up by discussing all of the terms as a group activity during class.Ask students whether any of the key terms are familiar to them already; use their responses to launch a discussion about the rest of the terms.
6 Key Terms (Continued) 4-6 participating (PAR) provider patient portal payerpolicyholderpreauthorizationpreexisting conditionpremiumpreregistrationpreventive medical servicesproviderprovider’s daily scheduleprovider selection boxreferralreferral numberschedule of benefitsTeaching Notes: See notes on Slide 5.
7 4.1 Scheduling Methods4-7Patient appointments may be scheduled via telephone or online.Patient portal—secure website that enables communication between patients and health care providers for tasks such as scheduling, completing registration forms, and making paymentsLearning Outcome: 4.1 Describe the two methods used to schedule appointments.Teaching Notes: Ask students why most patients use traditional methods of appointment scheduling. Encourage students to brainstorm the benefits of a patient portal. Benefits include giving the patient an element of control, allowing for real-time updates, being easily accessible for all parties, easing the transition into EHRs, etc. Use the responses as a springboard for discussion.
8 4.1 Scheduling Methods (Continued) 4-8Scheduling systems include these methods:Open hoursStream schedulingDouble-bookingWave schedulingLearning Outcome: 4.1 Describe the two methods used to schedule appointments.Teaching Notes: Compare and contrast the four types of scheduling; which method do students think is best, or does it depend? If it depends, what does it depend on?
9 4.2 New Versus Established Patients 4-9New patient (NP)—patient who has not received professional services from a provider (or another provider with the same specialty in the practice) within the past three yearsEstablished patient (EP)—patient who has received professional services from a provider (or another provider with the same specialty in the practice) within the past three yearsPreregistration—process of gathering basic contact, insurance, and reason for visit information before a new patient comes into the office for an encounterLearning Outcome: 4.2 Explain the method used to classify patients as new or established.Teaching Notes: Direct students’ attention to Figure 4.3 in the text – the flowchart to determine NP or EP. Provide various patient scenarios and have students walk through the flowchart to determine if the patient in each scenario is new or established.
10 4.3 Preregistration for New Patients 4-10During preregistration, new patients usually provide three types of information:Demographic informationBasic insurance informationReason for the visit (also known as the chief complaint)Learning Outcome: 4.3 List the three categories of information new patients provide during telephone preregistration.Teaching Notes: Demographics may include information such as name, address, gender, DOB, home/work/cell phone numbers, address, SSN, and marital status. Insurance info includes name of health plan, member’s plan ID number, name of policyholder, type of plan, need for a copay, and name of referring physician, if applicable.Ask students why so much demographic information is taken. What might it be used for?
11 4.3 Preregistration for New Patients (Continued) 4-11Participating (PAR) provider—provider who agrees to provide medical services to a payer’s policyholders according to the terms of the plan’s contractNonparticipating (nonPAR) provider—provider who chooses not to join a particular government or other health planLearning Outcome: 4.3 List the three categories of information new patients provide during telephone preregistration.Teaching Notes: Stress that encounters with nonPAR providers require more out-of-pocket payments from a patient.
12 4.4 Appointments for Established Patients 4-12Medical offices verify established patients’ information prior to an appointment; such information includes:changes to a patient’s address,changes to a patient’s health plan or employment.The reason for the visit should also be established to schedule the correct amount of time for the encounter.Patients’ account balances are checked as well.Learning Outcome: 4.4 Identify the information that needs to be verified for established patients when making an appointment.Teaching Notes: Ask students to discuss how electronic PM systems can assist with obtaining/verifying information for established patients. They may cite such things as the ability to make a quick assessment of whether a balance is due and the fact that information appears right on the screen rather than the office assistant’s needing to pull a patient chart.
13 4.5 Insurance Basics4-13Medical insurance—financial plan that covers the cost of hospital and medical carePolicyholder—person who buys an insurance plan; the insured, subscriber, or guarantorHealth plan—individual or group plan that either provides or pays for the cost of medical carePayer—health plan or programPremium—money the insured pays to a health plan for a health care policy; usually paid monthlyLearning Outcome: 4.5 Describe covered and noncovered services under medical insurance policies.Teaching Notes: For Slides 13-20, here are some options for covering the topic of insurance basics; choose as many activities as needed, or as time allows:List the terms on the board or on a worksheet. Ask students to discuss where they have used or heard these terms before; many of them should already be familiar with most of these terms.Provide sample insurance documents and ask students (possibly as a group activity) to identify the key pieces of information (name of policyholder, health plan, etc.) found on the document.Using Table 4.1 in the textbook, ask students to debate which type of health plan they would choose. Discuss the pros and cons of each type.Discuss the various types of government-sponsored health insurance: Medicaid, Medicare, TRICARE, CHAMPVA (page 195 in text).Reference Figure 4.4 in the text, the sample range of benefits sheet. Ask students what they notice about it – does it seem fair? comprehensive? lacking? Would they choose an insurance provider that offered similar benefits?
14 4.5 Insurance Basics (Continued) 4-14Benefits—amount of money a health plan pays for services covered in an insurance policySchedule of benefits—list of the medical expenses that a health plan coversProvider—person or entity that supplies medical or health services and bills for or is paid for the services in the normal course of businessLearning Outcome: 4.5 Describe covered and noncovered services under medical insurance policies.Teaching Notes: See notes on Slide 13.
15 4.5 Insurance Basics (Continued) 4-15Covered services—medical procedures and treatments that are included as benefits under an insured’s health planThese may include primary care, emergency care, medical specialists’ services, and surgery.Preventive medical services—care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening testsLearning Outcome: 4.5 Describe covered and noncovered services under medical insurance policies.Teaching Notes: See notes on Slide 13.
16 4.5 Insurance Basics (Continued) 4-16Noncovered services—medical procedures that are not included in a plan’s benefits; these things may include:Dental services, eye care, treatment for employment-related injuries, cosmetic procedures, infertility services, or experimental proceduresSpecific items such as vocational rehabilitation or surgical treatment of obesityPrescription drug benefitsTreatment for preexisting conditions—illnesses or disorders of a beneficiary that existed before the effective date of insurance coverageLearning Outcome: 4.5 Describe covered and noncovered services under medical insurance policies.Teaching Notes: See notes on Slide You may also want to discuss with students why certain services, like eye care, cosmetic procedures, and infertility services, are typically categorized as “noncovered services.”Ask students if it is right that preexisting conditions are not covered. Why might insurance companies have this rule? (Note that federal health care reform addresses this issue.)
17 4.5 Insurance Basics (Continued) 4-17Indemnity plan—type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefitsDeductible—amount that an insured person must pay, usually on an annual basis, for health care services before a health plan’s payment beginsCoinsurance—portion of charges that an insured person must pay for health care services after payment of the deductible amount; usually stated as a percentageLearning Outcome: 4.5 Describe covered and noncovered services under medical insurance policies.Teaching Notes: See notes on Slide 13.
18 4.5 Insurance Basics (Continued) 4-18Out-of-pocket—expenses the insured must pay before benefits beginFee-for-service—health plan that repays the policyholder for covered medical expensesCapitation—prepayment covering provider’s services for a plan member for a specified periodLearning Outcome: 4.5 Describe covered and noncovered services under medical insurance policies.Teaching Notes: See notes on Slide 13.
19 4.5 Insurance Basics (Continued) 4-19Managed care—system that combines the financing and delivery of appropriate, cost-effective health care services to its members; basic types include:Health maintenance organizations (HMOs)Point-of-service (POS) plansPreferred provider organizations (PPOs)Consumer-driven health plans (CDHPs)Out-of-network—provider that does not have a participation agreement with a planLearning Outcome: 4.5 Describe covered and noncovered services under medical insurance policies.Teaching Notes: See notes on Slide 13. You might also discuss why – knowing that costs will be higher – a patient would choose to go to an out-of-network provider.
20 4.5 Insurance Basics (Continued) 4-20Preauthorization—prior authorization from a payer for services to be providedCopayment (copay)—amount that a health plan requires a beneficiary to pay at the time of service for each health care encounterReferral—transfer of patient care from one physician to anotherLearning Outcome: 4.5 Describe covered and noncovered services under medical insurance policies.Teaching Notes: See notes on Slide 13.
21 4.6 Eligibility and Benefits Verification 4-21Except in a medical emergency, the following information should be obtained/verified from a patient’s health plan before an encounter:Patient’s general eligibility for benefitsAmount of the copayment for the visit, if one is requiredWhether the planned encounter is for a covered service that is medically necessary under the payer’s rulesPatients should be informed if their policy does not cover a planned service.Learning Outcome: 4.6 List the three main points to verify with the payer regarding a patient’s benefits prior to a visit.Teaching Notes: The biggest factor in determining a patient’s eligibility for benefits is employment status: if an employee moves from full- to part-time, or is terminated, coverage will end.Discuss what happens if a patient’s policy does not cover a planned service: patient may elect to go ahead with the procedure, but pay out-of-pocket. In most cases, a practice will have a patient sign specific paperwork, such as a Financial Agreement for Payment of Uncovered Services. Why would a practice do this?
22 4.7 Preauthorization, Referrals, and Outside Procedures 4-22Managed care payers often require preauthorization before a patient:sees a specialist,is admitted to the hospital, orhas a particular procedure.If the payer approves the service, it issues a preauthorization number that must be entered in the PM and included on the claim.Referral number—authorization number given by a referring physician to the referred physicianLearning Outcome: 4.7 Explain when a preauthorization number or referral document is required for a patient’s encounterTeaching Notes: Ask students why many insurance plans require preauthorization and referrals for specific services.
23 The Office Hours window contains four main areas: 4.8 Using Office Hours—Medisoft Network Professional’s Appointment Scheduler4-23The Office Hours window contains four main areas:Provider selection box—selection box that determines which provider’s schedule is displayed in the provider’s daily scheduleProvider’s daily schedule—listing of time slots for a particular day for a specific provider that corresponds to the date selected in the calendarOffice Hours calendar—interactive calendar that is used to select or change dates in Office HoursOffice Hours patient information—area that displays information about the patient who is selected in the provider’s daily scheduleLearning Outcome: 4.8 List the four main areas of Medisoft Network Professional’s Office Hours window.Teaching Notes: Explain that students will start Office Hours by clicking through the following sequence of tabs: Start > All Programs > Medisoft > Office Hours.Use Figure 4.15 in the textbook to provide visuals for the terms on the slide. Explain to students that Office Hours can be customized upon installation to fit the needs of different practices. Use Table 4.2 to show students the various toolbar buttons that are available.
24 4.9 Entering Appointments 4-24To enter an appointment in Medisoft Clinical:Select the appropriate provider from within the Office Hours program.Choose an appointment time slot.Complete the fields in the New Appointment Entry dialog box.Click the Save button to enter the information on the schedule.Learning Outcome: 4.9 Demonstrate how to enter an appointment.Teaching Notes: Explain that booking an appointment always begins with securing the desired provider. Depending upon the specific patient scenario, the office assistant may need to use Office Hours to search for an open time, look up a patient’s provider, or schedule an appointment for an established or new patient. Each scenario requires somewhat different steps. Tell students that the exercises associated with this part of their textbook will walk them through the various ways to set up and enter appointments in Medisoft Clinical.Assignment: Have students complete Exercises
25 4.10 Booking Follow-up and Repeating Appointments 4-25To create follow-up appointments in Office Hours:Click the Go to a Date shortcut button on the toolbar; the Go To Date dialog box will be displayed to allow a choice of date.After a future date option is selected, click the Go button to close the dialog box and begin the search.The future date will be located and displayed in the calendar schedule accordingly.Learning Outcome: 4.10 Demonstrate how to book follow-up and repeating appointments.Teaching Notes: Explain that follow-up appointments are scheduled for one certain time in the future, normally to check on treatment progression or to ensure that a patient has healed.Assign students to complete Exercise 4.6.
26 4.10 Booking Follow-up and Repeating Appointments (Continued) 4-26To create repeating appointments in Office Hours:Open the New Appointment Entry dialog box.Click the Change button; the Repeat Change dialog box is displayed.Make selections and enter information in the Repeat Change dialog box.When done, click the OK button, and then the Save button, to enter the repeating appointments on the schedule.Learning Outcome: 4.10 Demonstrate how to book follow-up and repeating appointments.Teaching Notes: Repeating appointments occur at the same time for a limited period of time, like “every Tuesday, at 3 pm, for the next 4 weeks.”Ask students to complete Exercise 4.7.
27 4.11 Rescheduling and Canceling Appointments 4-27To locate an appointment that needs to be rescheduled:Click the Appointment List option on the Office Hours Lists menu; the Appointment List dialog box appears.Use the Cut and Paste commands to move an appointment.Use the Cut command to cancel an appointment.Learning Outcome: 4.11 Demonstrate how to reschedule an appointment.Teaching Notes: After discussing the method for rescheduling an appointment, reference the Medisoft shortcut found on page 195 of the student text: simply right-clicking on the appointment will bring up the needed functions.Have students complete Exercise 4.8.
28 4.12 Creating a Patient Recall List 4-28To create or maintain a recall list in MNP:Click Patient Recall on the Lists menu; the Patient Recall List dialog box is displayed.Patients are added to the recall list by clicking the New button in the Patient Recall List dialog box or by clicking the Patient Recall Entry shortcut button; the Patient Recall dialog box is displayed.After the information has been entered in the dialog box, click the Save button.Learning Outcome: 4.12 Demonstrate how to create a recall list.Teaching Notes: Stress to students that the Recall function is in Medisoft Network Professional, NOT in Office Hours. Reference Figure 4.28 in the textbook for a sample Recall screenshot.Have students complete Exercise 4.9.
29 4.13 Creating Provider Breaks 4-29Office Hours break—block of time when a physician is unavailable for appointments with patientsTo set up a break for a current provider:Click the Break Entry shortcut button; the New Break Entry dialog box will appear.Enter the information in the dialog box, and click the Save button to enter the break(s).Learning Outcome: 4.13 Demonstrate how to enter provider breaks in the schedule.Teaching Notes: Ask students to give examples of provider breaks. Many will say “lunch” or “vacation,” but be sure they know that a seminar, surgery, or similar activity will also count as a break. Breaks are not just “free time.”Have students complete Exercise 4.10.
30 4.14 Printing Schedules4-30To print a provider’s schedule within Office Hours:Use the Appointment List option on the Office Hours Reports menu to view a list of all appointments for a provider for a given day.The report can be previewed on the screen or sent directly to the printer.Alternatively, click the Print Appointment List shortcut button.Learning Outcome: 4.14 Demonstrate how to print a provider’s schedule.Teaching Notes: Remind students that there are two options for locating appointment lists. The Appointment Lists option on the LISTS menu displays a list of all appointments in the database and is used to search by PATIENT. The Appointment List option on the REPORTS menu is used to search by PROVIDER.Have students complete Exercise 4.11.